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Keywords:

  • evaluation;
  • leadership;
  • midwives;
  • nurses;
  • professional identity

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

Aim

This study reports on an evaluation of an in-house nursing and midwifery leadership programme within a New Zealand District Health Board aimed at improving leadership capacity within clinical environments.

Background

The programme associated with this study is based on Practice Development concepts which aim to improve patient care and service delivery as well as empower practitioners to foster and support a transformational culture.

Methods

Mixed methods were used.

Results

Evidence indicated participants' self-confidence improved leading to a ‘growing up’. This was demonstrated in a number of ways: taking more responsibility for individual clinical practice, undertaking quality and safety roles as well as postgraduate study. These findings can be constructed in terms of linking leadership training with the development of professional identity.

Conclusions

This study provides evidence that in-house leadership programmes can provide front-line nurses and midwives with opportunities to enhance their professional identity and expand their skills in a variety of ways.

Implications for nursing management

Organisational investment in in-house programmes aimed at leadership skills have the potential to enhance patient care as well as improve the work environment for nurses and midwives. However, in-house programmes should be considered as augmenting rather than replacing tertiary education institutions' leadership courses and qualifications.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

The ebb and flow of leadership skill development for nurses, in New Zealand and internationally, has been influenced by a plethora of health sector reforms. The consequences for nursing in relation to reform and restructuring processes have been profound: significant reductions in registered nursing full-time equivalent positions, decreased job satisfaction levels, increased turnover rates, fragmentation of health care team relationships as well as negative effects on nurses physical and psychological well-being (Aiken et al. 2001, Cummings 2006, Oulton 2006, Carvalho & Santiago 2009). Policy changes resulting in negative outcomes for nursing and other health care staff have also been related to adverse patient outcomes, especially those evidenced via nursing sensitive indicators, such as urinary tract and surgical wound infections and pulmonary failure (Carryer et al. 2010).

One aspect of the reform process has been the introduction of managerial ideology, a market-based approach encouraging competitiveness and commodification of health care service delivery (Carvalho & Santiago 2009). In New Zealand, this ideological approach originally resulted in the decimation of clinical leadership roles in favour of non-clinical managers (Hornblow 1997, Gauld 2000, Fougere 2001, Sage et al. 2001) and, at its zenith, nursing budgets were lost to non-clinical managers, and senior nurse positions were replaced with new graduates (McCloskey & Diers 2005). While it could be argued that the pace of health sector reform in New Zealand has decelerated, changes are ongoing. Regionalization of core services plus the increasing use of Health Care Assistants in the acute and aged care settings are some examples of these. Nurse leadership roles such as Directors of Nursing have now been re-established, as have nurse-manager positions. However, the ability to control the nursing budget remains, to a large extent, outside the parameters of these roles (Carryer et al. 2010). Leadership, according to Redman (2006, p. 296), remains crucial to the future of nursing and the provision of quality patient care. Nurses need to be strategically involved in the planning, development, education and implementation of leadership competencies and skills (Redman 2006, McCallin et al. 2009), and these need to account for the present environment, not the past.

Twentieth-century leadership theories and models were based around a top-down authoritarian and bureaucratic approach which aimed to achieve maximum gains from economies and social systems predicated on industrial production (Uhl-Bien et al. 2007, Hanson & Ford 2010), and as such needed workers who were task-based. However, 21st century economic and social systems emphasize knowledge. Health care is an example of a knowledge-based industry. It is an environment replete with complex processes and networks as well as bureaucratic and hierarchical structures. In order to meet the demands and pressures inherent within such structures, leadership theories and models need to enable and support adaptability, learning, problem-solving, collaboration, innovation and change (Uhl-Bien et al. 2007, Hanson & Ford 2010).

Research investigating leadership skills required by nurses working within these knowledge-based environments reveal a range of pragmatic and metaphysical qualities. For example, nurses working within clinical settings not only need to be patient focused, they also need to be critical thinkers, clinically competent and confident using evidence-based practice, be able to initiate and manage change, as well as understand how the wider financial, political and social landscape impacts upon and influences health policy and direction (Cook 2001a, Davidson et al. 2006, Bretschneider et al. 2010, Casey et al. 2010). Other leadership skills detailed include goal setting and providing colleagues with motivation and support (Davidson et al. 2006). Stanley's (2008) views are more metaphysical in origin and he argues that attributes which are ‘values-base’ or ‘congruent’ are important when considering leadership characteristics. These include an approachable and open manner, role modelling values and beliefs, effective communication skills, decision-making ability and visibility. Advocacy is also considered a necessary component of clinical leadership in order to ensure optimal patient care (Sorensen et al. 2008). Authentic leadership is another values-based model. It incorporates ‘soft skills’, which requires leaders to ‘understand their own purpose, practice solid values, lead with heart, establish enduring relationships, and practice self-discipline’ (George 2003 cited in Shirey 2006, p. 260). Shirey points to a lack of empirical evidence surrounding this leadership model but argues that in the wake of recent behaviours seen in corporate and banking sectors, a leadership style incorporating ‘soft skills’ appears to have merit for organisations as a whole, as well as ‘at the front line or the point of care’ (Shirey 2006, p. 266). The soft skills and values-based approaches have synergy with Practice Development (PD) ideologies, which are described below, and form the basis of the leadership programme outlined in this study. It is also argued nurses require opportunities to learn about and practice leadership because up until recently scant recognition has been given to leadership being considered an intrinsic part of nursing's ‘skill-set’ (Johnson et al. 2010).

While there are numerous postgraduate courses pertaining to developing leadership and management skills, some specific to nursing and midwives and others more generic, within one New Zealand District Health Board (DHB), it was noted these programmes targeted people already in management or leadership positions. After extensive engagement with staff, Nurse Coordinators Practice Development (NCPDs) working with nurses and midwives throughout acute care and community-based settings became aware of a gap in relation to the career development of nurses who showed leadership potential. In light of this discovery, the NCPDs created a programme in 2007 called Pebbles, which aimed to support these nurses. In the initial phase, Pebbles was described as an ‘enrichment’ experience where a cohort of nurses and midwives were exposed to a variety of ideas and skill sets to develop their self-belief and self-efficacy. Raising levels of confidence as well as consciousness about the wider health environment were goals of the programme. As Pebbles continued, by 2009, the raison d'être of the programme altered to specifically focus on leadership development. This paper details an evaluation of the programme carried out in 2010, focusing on the analysis of participants' written comments and interview/focus group data.

Background

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

Pebbles nomenclature

When a pebble is dropped into a pool of water ripples occur. It was a ripples-of-influence metaphor that influenced the naming and ideological underpinnings of the leadership programme. In other words, it was envisaged that registered nurses (RNs) and midwives (MWs) who attended the programme would role model what they had learned back in their wards and units, thereby positively influencing the development of leadership skills and capacity in these areas.

Practice development theory and methodology

Practice development is an internationally recognized movement, originating in the UK and Ireland. Its theory and methods influenced the development, delivery and content of the leadership programme discussed in this paper. Practice development's purpose relates to improving patient care and service delivery. Practice development promotes the empowering of health care practitioners, both individually and collectively, through the development of a transformational culture which actively supports patient-centred care (Garbett & McCormack 2002, Manley & McCormack 2003). The main principles underlying PD, as proposed by Manley et al. (2008), are:

  • A workplace culture predicated on person-centered and evidence-based care.
  • Practice development activity occurring at a micro-system level (i.e. where most healthcare takes place) but receiving support from mezzo- and macro-systems (middle and upper level bureaucracies).
  • Work-place learning prioritized within clinical areas and formally supported by the organisation.
  • Integration and development of evidence from practice and evidence in practice.
  • Encouragement of creative and innovative thinking.
  • Sets of processes, including skilled facilitation, developed into site-specific skill sets.
  • Evaluations of all innovations; carried out as inclusive, participative and collaborative.

Practice development is values based and an important aspect of Pebbles is related to participants articulating their own philosophies and values; for example, why they chose nursing and midwifery as a profession, and the values they relied on in order to do their job. Part of this discovery phase was referred to as ‘the heart of their practice’. Facilitation underpins PD and is used to dispel and challenge the taken-for-granted attitudes people develop towards their individual practice and work environments, encouraging instead reflection, critical analysis, discussion and debate, as well as an ‘enabling’ culture. Individuals are vested with responsibility to enact change aimed at improving patient care and/or the nursing experience as opposed to relying on others or accepting the status quo (Manley & McCormack 2003).

The clinical leadership programme

Pebbles was run over a 6-month period, with participants released from clinical duties for a full day once a month for 6 months. Dates were provided to Charge Nurse Managers (CNMs)/Charge Midwife Managers (CMMs) well in advance to ensure rosters could be prepared accordingly. Facilitation of the programme was carried out by NCPDs with group discussions being the preferred format. Case studies, visiting the DHB library, reviewing and critiquing academic literature, as well as presentations by senior nurses (e.g. Director of Nursing) all formed part of the programme. Participants completed assignments between each session. Participants also presented an aspect of their clinical practice to the group.

Programme content

The content of the programme has been continually revised since its inception and is outlined in Table 1. Since 2010, the framework for Pebbles has focused on eight competencies identified by Huston (2008) as essential for nurse leaders' repertoire in 2020.

Table 1. Pebbles programme themes
2007–20092010
Day 1: IntroductionDay 1: Introduction
Ways of working (group rules)Ways of working (group rules)
Introduction to practice development (PD)Introduction to PD
Reflective models ‘Big picture’ thinking
‘Puzzling’Leadership skills 2020 (Huston 2008)
Personal philosophiesCommunication (Walsh et al. 2009)
Library visit
Day 2: Sourcing/working with knowledgeDay 2: Global health care perspectives
Knowledge waveParticipant reports/reflections
Evidence based practiceTrends in health care
Identifying and searching key websitesWorking with ‘fresh eyes’
Coaching models (Garfinkle 1984)
Clinical supervision/critical companionship ‘Puzzling’ (Walsh et al. 2008)
Evidence-based practice/library visit
Career planning
Day 3: Effective networkingDay 3: New technologies
Organisational structuresParticipant reports/reflections
Nursing directorate strategic planDecision making skills
Presentation by clinical nursing directorsEvidence in practice/change
Theories ‘Puzzling’ (Walsh et al. 2008)
Personal definitions of dignityParticipant presentations
Day 4: Exploring professional pathwaysDay 4: Political astuteness
Theoretical influencesParticipant reports/reflections
Navigating professional pathwaysCollaboration/team building
Self-carePolitical savvy
Presentations by nursing academics/leadersParticipant presentations
Day 5: PDDay 5: Coping with change
PD conceptsParticipant reports/reflections
Transactional analysisCase studies Health and Disability Commission
Workplace engagement ‘Heart of our practice’
Participant presentations
Day 6: Sharing knowledgeDay 6: Balancing authenticity and performance expectations
20-minutes presentation by each participantParticipant reports/reflections
Personal reflectionsNursing research
Course evaluationStrategies for aspiring leaders
Participant presentations
Course evaluation

Participant nomination

Charge Nurse/Midwife Managers nominate RN/MW staff for Pebbles. A cohort of 12 participants takes part in each programme.

The study

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

Aim(s)

The aim of the study was to ascertain what impact and influence Pebbles had on nurses and midwives and their clinical units.

Design

Mixed methods were used.

Sample/participants

The study was conducted using purposeful sampling (Creswell 2003). Rationale was based on programme participants, their nurse/midwife managers, and the PD facilitators having sufficient knowledge and understanding about the programme in order to contribute to its evaluation. At the time the study was conducted, 80 nurses and midwives had taken part in the leadership programme. Inclusion criteria was limited to RNs/MWs who had completed the entire programme (n = 60). Exclusion criteria included RNs/MWs still undergoing the programme (n = 20).

Details of questionnaire and focus group/interview participants are outlined in Table 2. Fifty-eight questionnaires were posted to eligible participants (two participants moved overseas and no contact details were available). A response rate of 65.5% (n = 38) was received with 74% (n = 28) writing in the comments section of the questionnaire. Interviews were also held with 18 participants: semi-structured individual interviews (n = 7 participants) and focus groups (n = 11 participants).

Table 2. Study participants
QuestionnaireNumber%Focus groups/individual interviews
Age, years
20–30718.4 
31–401231.6 
41–501128.9 
>50821.1 
Gender
Female3797.318
Male12.7 
Ethnicity
New Zealander337.115
European1542.9 
Maori38.61
British12.92
Indian12.9 
Asian25.7 
Training
New Zealand trained3181.6 
Overseas trained513.9 
Qualifications
PG Certificate635.3 
PG Diploma211.8 
Masters15.9 
Adult Teaching Cert.15.9 
Current studying PG211.8 
No PG qualification529.4 
Interviews/Focus groups
No. of participantsInterview methodCategory
  1. PG, postgraduate; CNM, Charge Nurse Manager; CMM, Charge Midwife Manager; PD, Practice Development.

4IndividualPebbles
6Focus groupPebbles
3IndividualCNM/CMM
2Focus groupCNM
3Focus groupNurse Coordinators PD

Data collection

The study was undertaken in two stages. First, quantitative data were gathered via a questionnaire. The questionnaire sought demographic data as well as information from 39 Likert-scale statements. The Likert-scale was a 7-point scale ranging from 1 = strongly disagree, 4 = undecided and 7 = strongly agree. The statements were constructed under five sub-headings: Pebbles programme; clinical practice; career; leadership; and Practice Development. Respondents were also provided with space on the questionnaire to insert written comments in response to the statement ‘Any other comments you would like to make about the Pebbles programme’. During initial analysis, broad themes from these comments were noted and further explored during individual interviews and focus groups.

A semi-structured approach was adopted for the individual interviews and focus group discussions. This method is appropriate for gaining an in-depth understanding of participants' views and allows researchers flexibility in relation to the order questions are asked as well as including clarification and probing questions (Minichiello et al. 1990). Participants were asked about their expectations of the programme, why they thought they had been nominated (or why they had nominated staff), what the experience of Pebbles had meant to them in relation to their clinical practice and professional/career development, likes/dislikes about the programme and their views on what constituted good leadership. Participants were also asked to describe the value of the programme – both to them as individuals, to clinical areas and to the organisation as a whole. All but two interviews were tape-recorded and transcribed verbatim. For the two remaining interviews, field-notes were taken. Interviews and focus groups lasted, on average, an hour.

Theoretical approach

A grounded theory approach (Glaser & Strauss 1999) was used in relation to analysing written comments and interview data from participants. This was consistent with one of the aim's of the study which was to explore participants' views of the Pebbles programme.

Data analysis

Data from returned questionnaires were entered into an Excel database (with each response being allocated a specific ID number) and then transferred to spss (IBM Corporation, Armonk, NY, USA) for analysis. All comments were transcribed into a Word document along with the corresponding Excel database ID number. Analysis of the written comments and interview/focus group data was undertaken by one social scientist and four academic nurses. Interviews were transcribed, coded and analysed thematically (May 1997, Creswell 2003). The main themes were: expectations, confidence, aspiration, resilience, ‘big picture’ and, value and investment. Further scrutiny of the data and a review of the literature also revealed an emerging theory; that of the relationship between leadership development, maturity and professional identity.

Rigour

Triangulated data strengthens the credibility of research findings (Liamputtong 2009). The questionnaire was designed by P.M., reviewed by four senior nursing academic researchers, and tested by two RNs to ensure face validity and reliability. To mitigate against any potential bias, L.D., an NCPD involved in the setting up and facilitation of the programme, and also a member of the research team, was excluded from undertaking interviews and analysis of data. Further strategies relating to data collection included the principal investigator (P.M.) conducting all interviews, keeping a research diary and field notes and undertaking an extensive literature review. Neither P.M. nor K.W., C.M., W.C. and K.M. (see 'Acknowledgements') had a role in the programme itself. Participants own words together with their written comments have been used to illustrate the data analysis and theoretical development processes.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

As the themes (confidence, aspiration and big picture) illustrate, Pebbles provided participants with an opportunity to pause and reflect on their own clinical practice as well as their professional development needs and career aspirations. Learning about the complex nature of health care delivery enabled participants to engage in mature discussions about how organisational and political imperatives affected their work environment. Clinical competence and the ability to utilize evidence based when required is also an example of an RN or midwife who is professionally mature and confident with their professional identity.

Confidence

Confidence was a recurring theme during interviews with participants. For example, many of the nurses talked about how being nominated by their CNM/CMM together with what they learned throughout the duration of the programme had increased their confidence:

‘So the fact that [my CNM]…actually thinks I am better than I think I am…thinks I am capable of maybe being more than I am, that really spoke a lot to me.’ [Pebble 3]

As the following extract demonstrates, not only did the participant gain in confidence, but a wider appreciation of the organisation has helped her remain committed to her profession:

‘I think it has probably given me more confidence [dealing with patients as well as clinical situations]…I love working in the clinical area but I wouldn't love it if I hadn't done Pebbles. I wouldn't have found the heart of my practice…I wouldn't have the power to stay…I think knowing why we do things makes it better.’ [Midwife 1]

Questionnaire responses included:

‘I'm more motivated to take on different roles and I'm more confident in my ability to communicate to a team.’ [RN27]

‘Pebbles offered great insight into what was achievable as a nurse. It gave confidence and taught skills to manage self and career setting goals.’ [RN28]

CNMs/CMMs who nominated RNs and midwives for the programme also described how their nominees had demonstrated improved levels of confidence within the clinical environment:

‘She became more confident in her abilities…she was able to lead the shift when necessary…deal with difficult situations that were clinical or conflict…would put her hand up for additional portfolios. I couldn't ask for anything more really from someone who is only a few years out of her training.’ [CNM1]

‘She has been managing some really complex cases…she's kept me in the loop…but has sort of taken over a role of supporting everyone in the team…she'll also now speak up in meetings and has the confidence to contribute her point of view.’ [CNM5]

Aspiration

Aligned with the theme of confidence is that of aspiration. Both these themes overlap but data revealed many participants gained insight into and confidence about their careers. This resulted in the uptake of postgraduate education or a change in career direction (or both). For example, participants talked about taking responsibility for researching best-evidence information to use in their clinical practice as well as generally looking to up-skill their nursing knowledge through postgraduate study:

‘I'm actually being the grown-up, not looking to someone else…having the initiative to actually go out and be a bit more proactive, that is what Pebbles did for me…I think it was just the sense of confidence and needing to take that step forward and it was actually the discussion on management and needing proof…If I don't know about a particular condition then I will find out through appropriate sources…what the current research is saying. I am taking responsibility for myself.’ [Pebble 2]

‘Pebbles has actually driven me to take steps, instead of wondering about certain medications I will actually look up the research or try to find out if there are any clinical trials underway.’ [Pebble 3]

‘I definitely push myself to do more since I've attended Pebbles…I started my first paper, my certificate in March as soon as I finished [Pebbles] and then last year I actually was the first CNS [Clinical Nurse Specialist] intern they've employed.’ [Pebble 5]

Responses reflecting attitudinal changes were also evident in the completed questionnaires. For example one nurse wrote:

‘I was inspired to look into postgrad studying and I'm amazed at how much it has helped my practice and thought processes…I may not have considered study modules if I hadn't completed Pebbles and I feel it has been instrumental in my progress over the last two years.’ [RN13]

Questionnaire results also showed that 22 nurses indicated Pebbles had either influenced them to continue with or enrol in postgraduate study compared with six who were undecided and 10 who responded negatively. Out of 38 responses, 30 nurses claimed to have changed some aspects of their clinical practice and again 22 stated they accessed the DHB's medical library more frequently since attending the programme.

Big picture

Another aspect relating to maturity was exposed when participants spoke about how Pebbles had helped them see what they viewed as ‘the big picture’:

‘I think probably the biggest change [for me] was communication with other people…colleagues and other members of staff and managers and managers’ managers! I sort of saw a bigger picture…a better understanding of the hierarchy within the organisation…made them more accessible… Knowing people's roles, who they are, what they do…realising the extent of what goes on in your organisation.’ [Pebble 4]

‘[learning about…] different management levels – like who does what and why they do this and about funding…and how they had health targets…it's very narrow-minded in the wards and in other areas just concentrating on your own practice and not really thinking about the broader picture…I feel I may have a little more tolerance for change and may understand some of the pressures that are put upon management…just a little bit more insight.’ [Pebble 8]

Again, questionnaire respondents also referred to the benefits of gaining knowledge about the wider organisational and health policy imperatives:

I have a greater understanding of decision-making and change processes and no longer feel so disempowered. [RN11].

The opportunities to meet with leaders within the DHB…was a great way to break down barriers and develop a deeper understanding of why some decisions are made and to take time to look at the bigger picture. [RN38].

The big picture trope revealed a change in the ‘us vs. them’ mentality sometimes expressed by nurses towards nursing and executive management. Participants mentioned that by attending the programme and being given opportunities to meet people within the organisation ‘whose names are on the bottom of things’ and hearing about their background and careers, they developed a more mature and informed understanding of what these roles involved and the constraints people ‘up the hierarchy’ operated under. While some participants reported being inspired to look at leadership or management positions as potential career options, nurses also described how the programme had reaffirmed their commitment to clinical practice:

‘No…[the programme] hasn't made me want to be a manager…it has made me want to enhance what I do and do it better and stronger.’ [Pebble 4]

Limitations of the study

This study was limited by its small sample size and therefore it is not possible to generalize the findings to all nurses and midwives who have either participated in or nominated staff for Pebbles. Although participation rates were satisfactory for the questionnaire, the response rate for individual interviews/focus groups was poor and lower than anticipated. One aim of the study was to ascertain whether a linkage could be shown between programme attendance and a positive impact and influence within participants' clinical units. Although anecdotal evidence appears to support such a contention, further research is required to ascertain whether this is the case.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

Study participants are considered to have matured professionally and psychologically. In-depth analysis of written comments and interview data together with a literature review revealed an emerging theme linking leadership development to maturity and formation of professional identity.

Maturity and professional identity

Maturity is a trait evidenced within an individual's professional and psychological persona through the way in which they exhibit an aptitude and a willingness to assume responsibility for managing their own behaviour (Canilho & Alves 2010). Canilho and Alves (2010) describe professional maturity as possessing requisite knowledge and training in order to carry out a particular job and psychological maturity displayed through self-confidence and dedication. Research indicates that providing learning and development opportunities for RNs produces confident and committed workplace behaviours (Johnson et al. 2010, MacPhee et al. 2011) as well as high-quality patient care (Large et al. 2005).

If responsibility is considered an intrinsic component to the evolution of an individual's professional maturity, it is also a cornerstone in the formation of a person's professional identity. Evidence suggests that as medical students progress their careers, the responsibilities they assume, together with the relationships they form with patients and colleagues, is instrumental in developing a ‘professional identity’ (Moss & McManus 1992, Radcliffe & Lester 2003, Hayes et al. 2004). This maturing in regard to professional roles can sometimes be attributed to age; for example mature students and the life experience they bring with them as opposed to students straight from school (Shacklady et al. 2009). Similarly nurses' professional identity and maturation occurs as they reflect on their responses to what occurs within clinical settings (Sumner 2010). Sumner introduces the concept of three stages (A, B and C) of ‘moral’ maturity: preconventional, conventional and postconventional; all relating to Benner's (1984) novice to expert stages. The novice nurse is task-orientated and rule bound and tends towards a depersonalized patient care model where he or she ‘speaks’ as opposes to ‘listens’ to patients. At this stage, there is minimal self-reflection. Level B nurses practice with more confidence although they are still mindful of organisational directives in relation to patient care and are unlikely to question these. There is more interactive communication between the patient and nurse and while self-reflection is happening, it is unlikely to lead to changes being suggested in regard to patient care. According to Sumner (2010), it is at Level C that ‘moral maturity’ is achieved because of a synthesis of theory, practice and experience. The ability to critically reflect on patient needs within a holistic paradigm and subsequently negotiate plans of action, even if they involve challenging organisational and professional directives, is more likely to occur. Sumner (2010, p. 167), borrowing from Schon (1983), refers to this process as ‘reflection-on-action and reflection-in-action’. While time and experience are prerequisites to this happening, it is suggested that the Pebbles course accelerates this process for participants.

Big picture

Such an example of participants' maturation was evident through their appreciation of the ‘big picture’. As previously alluded to, one of the manifestations of the health reforms of the past two to three decades has been first the dis-establishment of nursing leadership roles and then their reincarnation. This environment has, to some extent, made nursing both invisible and silent, a situation which impacts upon nurses' professional identity (Ohlen & Segesten 1998). As revealed in the findings outlined above, Pebbles provided participants with an opportunity to not only reflect on their nursing practice, but also on their own action to the wider socio-political issues they were confronted with. Their responses indicated a maturing attitude towards work responsibilities. As Johnson et al. (2010, p. 610) contend, nurses should be prepared to broaden their ideas about responsibility to not only encompass core nursing tasks but to also ‘accept greater accountability and responsibility for the delivery of patient care through critical thinking, reflective practices and application of clinical skills’. According to McCallin et al. (2009) nurses throughout the professional hierarchy often have little idea of health policy and its implications. These authors (McCallin et al. 2009, p. 43 their emphasis) suggest that all nurses need to make a….

‘…conscious effort to develop political awareness and to appreciate the significance of current, professional-strategic alliances. Such strategies impact leadership succession planning, not to mention the future of the profession…it is most important that all nurses take a broader view of the nursing profession and its leadership potential that is situated in the wider socio-political world in which it takes place.’

According to Sorensen and Hall (2011), the ‘big picture’ trope is not just about ‘knowledge’ – whether it be practical nursing or theoretical knowledge – but also involves an in-depth understanding of the social, political, economic and managerial worlds and includes an appreciation of how these impact on the mechanisms of health care delivery to the general population as well as within discreet clinical settings. For instance, because health care has become increasingly subjected to managerial ideologies, it behoves nurses and midwives to ensure they are financially literate. In other words, they need to possess a clear understanding of budgets and the implications of these on decision-making processes and the acquisition of resources (Sherman & Pross 2010). The results of this study indicate that participants in general now possess a deeper understanding and appreciation of the wider health environment and the role of management at both organisational and nursing levels. Notwithstanding this, the ‘big picture’ perspective also includes political savvy. As Huston (2008) suggests, politics is ubiquitous and therefore it is essential that nursing and midwives have a clear understanding of the politics at play within their organisations in order to influence policy and action. This finds them better placed to intervene and advocate for patients as well as nursing and midwifery professional issues. However, our study did not reveal whether participants had chosen to become more politically active.

Confidence

Confidence is also an indication of maturity and a heightened sense of professional identity. As participants in this study showed, even the process of being nominated for Pebbles by their CNM/CMM provided a confidence boost. The literature also supports these views because it appears that nurses who are given opportunities to develop leadership skills demonstrate improved levels of confidence which are then transferred to the practice setting. Examples of this include insight into professional practice and the use of evidence-based practice in order to optimize patient care; in-depth understanding of and receptiveness towards organisational priorities and change management processes; problem-solving capabilities; and an awareness of leadership skills and how best to utilize these within a clinical environment to improve the experience for patients and the health care team (MacDonald & Ling 2002, Cummings 2006, Sherman & Pross 2010, Dyess & Sherman 2011). Working clinically, nurses' ability to contribute information as well as be involved in decision-making processes at both ward/unit and professional levels is often reliant on overcoming barriers such as nursing hierarchies and challenging the perceived value of nursing from members of the wider health care team, as well as institutional and corporate priorities (Sorensen et al. 2008).

Cook (2001a, p. 40 our emphasis) argues ‘continual investment needs to be made in the clinical leadership resource to influence and shape both policy and practice’. He (Cook 2001b) further purports that such investment is required throughout the RN continuum, i.e. building leadership capacity at all levels of nursing (and midwifery). Sherman and Pross (2010) assert that learning and development opportunities for nurses result in improved patient outcomes and staff retention rates. Pebbles participants reflected these sentiments; they described the programmes as an investment in both individuals and the organisation. From an individual perspective, the programme offered participants a chance to reflect on their practice, career plans and professional identity. From an organisational perspective, the programme was considered to have the potential to offer the DHB an opportunity to strategically develop a pool of talented and committed staff who would be well placed to meet future demands with regarding to providing good quality health care. As one of the participants voiced:

‘I would say Pebbles is the breeding ground of, such a cliché, but the future of the DHB or for any people who are thinking of moving on…if you can capture people's enthusiasm before it disappears…I think this programme is a good reflection of it's not about having just a job…it is capturing the future really and giving you the confidence to steer yourself in the future direction.’ [Pebble 2]

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

The results of this study provide an example of how an in-house nursing and midwifery leadership programme has been pivotal in developing leadership skills for clinically-based nurses and midwives. Participants maturation and a heightened sense of professional identity are considered attributes essential for knowledge-based working environments because flexibility, innovation, adaptability, communication and critical thinking skills will be required to meet the challenges of delivering health care in the 21st century. Nursing and midwifery management therefore need to consider investing in in-house leadership programmes as part of workforce succession planning strategies. A stair-casing approach to leadership development will ensure skills and capacity are continually built up and enhanced. However, in-house leadership programmes should be considered an augmentation to, not replacement of, tertiary education institutions' leadership courses and qualifications.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

We would like to acknowledge all nurses and midwives who have been involved in the Pebbles programme and thank those who gave of their time in responding to the questionnaire and/or interviews. Thanks also to Jane Lawless and Rhonda McKelvie, who along with Lindsay contributed so much to the setting up and facilitation of the Pebbles programme. We also acknowledge the input of Ken Walsh, Cheryle Moss, Wendy Cross, Kay McCauley and Robyn Cant to this study. We would also like to thank Veronique Gibbons, Jacquie Kidd and Lesley Macdonald for their comments in regard to drafts of this paper. Thank you also to the reviewers for their comments.

Source of Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical Approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References

Participation in the study was voluntary. All research participants received a study covering letter and an information sheet. Participants who were interviewed also received a consent form to sign. Research ethics permission was obtained from the Northern Y Regional Ethics Committee, New Zealand NTY10/06/054

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. Source of Funding
  11. Ethical Approval
  12. References
  • Aiken L., Clarke S., Sloane D. et al. (2001) nurses' reports on hospital care in five countries. Health Affairs 20 (3), 4353.
  • Benner P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Addison-Wesley, CA.
  • Bretschneider J., Glenn-West R., Green-Smokenski J. & Richardson C. (2010) Strengthening the voice of the clinical nurse: the design and implementation of a shared governance model. Nursing Administration Quarterly 34 (1), 4148.
  • Canilho P. & Alves H. (2010) Are leadership styles and maturity in healthcare teams synchronized? The IUP Journal of Organizational Behaviour 9 (3), 727.
  • Carryer J., Diers D., McCloskey B. & Wilson D. (2010) Effects of health policy reforms on nursing resources and patient outcomes in New Zealand. Policy, Politics & Nursing Practice 11 (4), 275285.
  • Carvalho T. & Santiago R. (2009) Gender as a ‘strategic action’: new public management and the professionalization of nursing in Portugal. Equal Opportunities International 28 (7), 609622.
  • Casey M., McNamara M., Fealy G. & Geraghty R. (2010) nurses' and midwives' clinical leadership development needs: a mixed methods study. Journal of Advanced Nursing 67 (7), 15021513.
  • Cook M. (2001a) The renaissance of clinical leadership. International Nursing Review 48, 3846.
  • Cook M. (2001b) The attributes of effective clinical nurse leaders. Nursing Standard 15 (35), 3336.
  • Creswell J.(2003) Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, 2nd edn. Sage Publications, Thousand Oaks, CA.
  • Cummings G. (2006) Hospital restructuring and nursing leadership: a journey from research question to research program. Nursing Administration Quarterly 30 (4), 321329.
  • Davidson P., Elliott D. & Daly J. (2006) Clinical leadership in contemporary clinical practice: implications for nursing in Australia. Journal of Nursing Management 14, 180187.
  • Dyess S. & Sherman R. (2011) Developing the leadership skills of new graduates to influence practice environments: a novice nurse leadership program. Nursing Administration Quarterly 35 (4), 313322.
  • Fougere G. (2001) Transforming health sectors: new logics of organizing in the New Zealand health system. Social Science & Medicine 52, 12331242.
  • Garbett R. & McCormack B. (2002) A concept analysis of practice development. Nursing Times Research 7 (2), 87100.
  • Gauld R. (2000) Big bang and the policy prescription: health care meets the market in New Zealand. Journal of Health Politics, Policy and Law 25 (5), 815844.
  • Garfinkle H. (1984). Studies in Ethnomethodology. Polity Press, Malden, MA.
  • Glaser B. & Strauss A. (1999) The Discovery of Grounded Theory. Strategies for Qualitative Research. Aldine de Gruyter, New York, NY.
  • Hanson W. & Ford R. (2010) Complexity leadership in healthcare: leader network awareness. Procedia, Social and Behavioural Sciences 2, 65876596.
  • Hayes K., Feather A., Hall A. et al. (2004) Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students. Medical Education 38, 11541163.
  • Hornblow A. (1997) New Zealand's health reforms: a clash of cultures. British Medical Journal 314, 1892.
  • Huston C. (2008) Preparing nurse leaders for 2020. Journal of Nursing Management 16, 905911.
  • Johnson A., Hong H., Groth M. & Parker S. (2010) Learning and development: promoting nurses' performance and work attitudes. Journal of Advanced Nursing 67 (3), 609620.
  • Large S., Macleod A., Cunningham G. & Kitson A. (2005)A Multiple Case Study Evaluation of the RCN Clinical Leadership Programme in England. RCN Institute, London. Available at: http://www.rcn.org.uk/-data/assets/pdf_file/0010/78643/002502.pdf, accessed 16 March 2012.
  • Liamputtong P.(2009) Qualitative Research Methods, 3rd edn. Oxford University Press, South Melbourne,Vic.
  • MacDonald A. & Ling J. (2002) Growing leaders: preparing the workforce for the future. Nursing Management 8 (10), 1014.
  • MacPhee M., Skelton-Green J., Bouthillette F. & Suryaprakash N. (2011) An empowerment framework for nursing leadership development: supporting evidence. Journal of Advanced Nursing 68 (1), 159169.
  • McCallin A., Bamford-Wade A. & Frankson C. (2009) Leadership succession planning: a key issue for the nursing profession. Nurse Leader 7 (6), 4044.
  • McCloskey B. & Diers D. (2005) Effects of New Zealand's health reengineering on nursing and patient outcomes. Medical Care 43 (11), 11401146.
  • Manley K. & McCormack B. (2003) Purpose, methodology, facilitation and evaluation. Nursing in Critical Care 8 (1), 2229.
  • Manley K., McCormack B. & Wilson V. (2008) Introduction. In International Practice Development in Nursing and Healthcare (K. Manley, B. McCormack & V. Wilson eds), pp. 116. Blackwell Publishing, Oxford.
  • May T. (1997) Social Research: Issues, Methods and Process, 2nd edn. Open University Press, Buckingham.
  • Minichiello V., Aroni R., Timewell E. & Alexander L. (1990) In-depth Interviewing: Researching People. Longman Cheshire, Melbourne, Vic.
  • Moss F. & McManus I. (1992) The anxieties of new clinical students. Medical Education 26, 1720.
  • Ohlen J. & Segesten K. (1998) The professional identity of the nurse: concept analysis and development. Journal of Advanced Nursing 28 (4), 720727.
  • Oulton J. (2006) The global nursing shortage: an overview of issues and actions. Policy, Politics & Nursing Practice 7 (3), 34S39S.
  • Radcliffe C. & Lester H. (2003) Perceived stress during undergraduate medical training: a qualitative study. Medical Education 37, 3238.
  • Redman R.W. (2006) Leadership succession planning: an evidence-based approach for managing the future. Journal of Nursing Administration 36 (6), 292297.
  • Sage D., Degeling P., Coyle B., Perkins R., Henderson S. & Kennedy J. (2001) Hospital reform strategies: professional subculture attitudes and beliefs of clinicians and managers in two New Zealand hospital groups. Health Manager 8 (3), 913.
  • Schon D. (1983) The Reflective Practitioner: How Professionals Think in Action. Temple Smith, London.
  • Shacklady J., Holmes E., Graham M., Davies I. & Dornan T. (2009) Maturity and medical students' ease of transition into the clinical environment. Medical Teacher 31, 621626.
  • Sherman R. & Pross E. (2010) Growing future leaders to build and sustain health work environments at unit level. Online Journal of Issues in Nursing 15 (4. http://web.ebscohost.com/ehost/delivery?vid=5&hid=8&sid=bb53819d-2afl-4c99-a3 (accessed on 19 May 2010).
  • Shirey M. (2006) Authentic leaders creating healthy work environments for nursing practice. American Journal of Critical Care 15 (3), 256267.
  • Sorensen R., Iedema R. & Severinsson E. (2008) Beyond profession: nursing leadership in contemporary healthcare. Journal of Nursing Management 16, 535544.
  • Sorensen E. & Hall E. (2011) Seeing the big picture in nursing: a source of human and professional pride. Journal of Advanced Nursing 67 (10), 22842291.
  • Stanley D. (2008) Congruent leadership: values in action. Journal of Nursing Management 16, 519524.
  • Sumner J. (2010) Reflection and moral maturity in a nurse's caring practice: a critical perspective. Nursing Philosophy 11, 159169.
  • Uhl-Bien M., Marion R. & McKelvey B. (2007) Complexity leadership theory: shifting leadership from the industrial age to the knowledge era. The Leadership Quarterly 18, 298318.
  • Walsh K., Moss C., Lawless J., McKelvie R. & Duncan L. (2008) Puzzling practice: a strategy for working with clinical practice issues. International Journal of Nursing Practice 14 (2), 94100.
  • Walsh K., Jordan Z. & Apolloni L. (2009) The problematic art of conversation: communication and health practice evolution. Practice Development in Health Care 8 (3), 166179.